Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellbridge Of Fenton during CMS and state inspections, most recent first.
Kitchen sanitation and hand hygiene deficiencies were observed in the food service area. An overhead spray nozzle was hanging inside the sink basin near the dishwashing area, yellow residue was seen on the interior wall of the ice machine, and a staff member removed gloves and put on new gloves without washing hands during food prep. The CDM/Culinary Specialist acknowledged the equipment issues and stated staff are supposed to wash hands after removing and before donning gloves.
Call Lights Not Within Reach, Delayed Response, and Lack of Respectful Care: Multiple residents reported long waits for call lights to be answered, including waits of 30 minutes or more, and said staff sometimes answered the light but did not return to help. A resident with intact cognition was observed waiting 18 minutes after activating a call light, while another resident had a call light tied out of reach and a third had a call light on the floor. Residents and a POA also reported staff entering rooms with little knocking, using phones or computers during care, and not listening to resident requests.
Two residents were involved in a physical altercation near the café line, after which a nurse separated them and documented new, bleeding facial abrasions for both, cleaned with normal saline and left open to air, with notation that the physician was notified. One resident, with Alzheimer’s dementia and multiple comorbidities but intact cognition, had a documented facial abrasion, yet the subsequent physician note only listed an altercation as the chief complaint and did not describe the facial injury or a related physical exam, and the behavior care plan referenced the altercation without noting injury. The other resident, with autism, mild intellectual disability, epilepsy, mood disorder, and cardiovascular comorbidities, had a larger cheek abrasion documented by nursing, but the physician note likewise only referenced an altercation without a skin assessment or mention of being hit in the face; a later provider note documented normal skin findings. Surveyors found there was no timely physician assessment or documentation of the facial wounds for either resident following the incident, despite facility policy requiring physician supervision of medical care and participation in assessment and monitoring of changes in status.
The facility failed to provide timely NOMNC and ABN notices for two residents whose Medicare Part A skilled coverage was ending. For one resident, staff misidentified the last covered day and missed both notices before the resident converted to private pay; for the other, the NOMNC was issued but the ABN documentation had an altered date with whiteout, and the resident’s wife reported signing papers during a later visit. The BOM and SW acknowledged the notice issues, and corporate staff had no comment during QAPI review.
Failure to provide ADL assistance was identified for a resident with stroke, psychiatric diagnoses, and intact cognition who needed substantial/maximal help with bathing and personal hygiene. Staff observed the resident eating in bed with chocolate on nearby surfaces and did not clean the resident’s hands or offer handwashing before meals. The resident’s fingernails were long with debris and dried red-tainted material around the cuticles, and the DON acknowledged the resident needed attention and that his hands would need to be washed.
Unsecured Medication Left at Bedside: A resident with severe cognitive impairment had a white pill found sitting on her over-bed tray by a family member. Staff could not initially identify the pill, later confirmed it was prednisone matching the resident’s AM order, and the nurse said she had witnessed the resident take her meds but did not know how the pill ended up unsecured at the bedside.
Failure to follow EBP during wound care and PEG tube care for two residents. One resident with a wound and prior toe amputation had gauze placed directly on the bed during dressing care, and staff did not consistently use barriers. Another resident with a PEG tube, wound, and foley was provided tube feeding medication administration and ostomy care with gloves only at first, without a gown, and supplies were placed on the bedside table without a barrier.
The facility failed to ensure timely response to call lights, affecting several residents' dignity and care. A resident with multiple health issues couldn't reach their call light, while others reported long delays in response, leading to accidents. One resident was left in the bathroom for 16 minutes without assistance, and staff were observed not responding promptly to requests for help.
A facility's medication error rate reached 20.69% due to improper administration practices. An LPN failed to prime an insulin pen and administered insulin after a resident ate. Another resident received a Lidocaine patch with Menthol instead of plain Lidocaine, and was not instructed to rinse after using Symbicort. An RN administered multiple eye drops without waiting between doses or instructing the resident to close their eyes, violating facility policy.
The facility failed to properly label, store, and dispose of medications, leading to unsecured controlled substances, reused syringes, and expired or undated medications in storage rooms. Additionally, a resident's room contained unsecured iodine, which the resident was unaware of. Staff acknowledged improper practices despite previous training, and no policy on medication storage was provided.
The facility failed to update and individualize care plans for two residents, leading to safety risks and unmet needs. A resident with a history of falls was unsupervised outside, resulting in a hip fracture. Another resident developed a skin impairment that was not documented or addressed in the care plan. The deficiencies highlight a lack of documentation and communication among staff.
A resident with multiple health issues developed a significant skin excoriation due to limited movement from a small bed. Despite an assessment by multiple staff, there was no documentation or updated care plan for the skin impairment. Miscommunication among staff led to a lack of documentation, and the facility failed to provide the requested skin care policy.
A resident with a history of falls and dementia was observed being pushed in a wheelchair without footrests by a CNA, leading to potential injury risks. The CNA acknowledged the lack of footrests and expressed surprise at the facility's practices compared to previous workplaces. The facility lacked a specific policy on wheelchair footrest use, and no care plan addressed this aspect for the resident.
A facility failed to have a physician's order and proper documentation for catheter changes for a resident with kidney failure and other conditions. The resident recalled a recent catheter change due to leakage, but there was no documentation in the EMR. A nurse confirmed the need for an as-needed order and documentation, aligning with the facility's catheter care policy.
A facility failed to provide timely dialysis care and documentation for a resident with acute kidney failure and chronic kidney disease. The facility did not enter a physician's order to monitor the dialysis perma-cath site until after the resident had already received dialysis twice. Additionally, the required Wellbridge Dialysis Assessment form was incomplete for one session and missing for another, as confirmed by the Infection Control Nurse.
The facility failed to maintain sanitary conditions and proper maintenance of kitchen equipment, affecting 81 residents. Observations included a calcium-like build-up on the ice machine door gasket, improperly cleaned knives and silverware, and a leaking dishwasher causing standing water. The Infection Control Nurse was not adequately trained for kitchen inspections, and there was no documentation of equipment checks.
The facility failed to ensure proper hand hygiene during medication administration for two residents. An RN did not perform hand hygiene before entering residents' rooms or before preparing and administering medications. A Clinical RN confirmed that hand hygiene should be performed, as per the facility's policy.
The facility failed to ensure residents' dignity and timely care by not keeping call lights within reach or responding promptly, leading to unmet needs and frustration. Reports of staff disrespect and abuse were noted, with one resident feeling unsafe. Additionally, poor communication with resident representatives led to a medication error, contributing to a resident's death.
A resident on anticoagulant therapy experienced two falls, with the second fall leading to a decline in mental status. The facility failed to promptly inform the physician of the resident's condition, resulting in a delay in treatment and hospitalization for a brain bleed. The nurse manager noticed changes in the resident's condition but did not communicate them effectively, and the nurse practitioner did not evaluate the resident in person. The family insisted on hospital evaluation, where the brain bleed was diagnosed.
A resident with severe cognitive impairment developed in-house pressure ulcers on both elbows. The facility delayed entering physician orders for wound care and updating the care plan. Nursing staff identified the wounds but did not promptly update the care plan or enter orders, contrary to facility policy.
The facility failed to store nebulizer equipment properly and follow physician's orders for oxygen administration for two residents. A resident with chronic respiratory failure had a nebulizer with liquid left in the chamber and was receiving oxygen at an incorrect rate. Another resident with severe cognitive impairment had a nebulizer mask with fluid left on an overbed table. Facility policies for nebulizer equipment and oxygen administration were not adhered to.
A facility failed to obtain timely physician visit documentation for a resident, leading to delayed treatment orders. The resident, with Atrial Fibrillation and other conditions, experienced a gap in physician visits exceeding 60 days, against policy. The NP did not examine the resident post-fall, as symptoms were considered baseline. The resident later had a brain bleed diagnosis after a fall.
A nurse failed to follow Enhanced Barrier Precautions (EBP) by not wearing the required PPE during wound care for a resident with severe cognitive impairment and multiple medical conditions. Despite a physician's order for EBP, the nurse and a hospice caregiver did not use gowns and gloves, as mandated for high-contact care activities. The infection control nurse confirmed the expectation for staff to adhere to EBP guidelines.
Two residents experienced falls without adequate post-fall monitoring or meaningful interventions. One resident fell during a hospice respite stay without documented neurological checks, while another resident had three consecutive falls with injuries due to inadequate toileting and ineffective interventions. The facility failed to follow its fall reduction policy, resulting in missing documentation and inconsistent monitoring.
The facility failed to ensure communication between clinical services and social services to develop a person-centered care plan for a resident with schizophrenia and other medical conditions, resulting in unmet care needs and emotional distress. The resident exhibited significant behavioral issues, and the facility's response was inadequate, leading to an incident where the resident was found alone in a dark bathroom, covered in feces, and emotionally distressed.
Kitchen sanitation and hand hygiene deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area during observation, interview, and record review. During the kitchen tour with the Certified Dietary Manager/Culinary Specialist and Chef, an overhead spray nozzle was observed hanging inside the sink basin near the dishwashing area. The Certified Dietary Manager/Culinary Specialist stated there was a work order to fix the overhead spray nozzle. The report also noted yellow residue on the interior wall of the ice machine in the kitchen, and the Certified Dietary Manager/Culinary Specialist stated the ice machine is cleaned every month. During lunch observation, a staff member was observed removing gloves and putting on new gloves without washing hands during food preparation in the kitchen. When interviewed, the Certified Dietary Manager/Culinary Specialist stated staff are supposed to wash hands after removing and putting on new gloves. The report cited the 2022 Food Code for backflow prevention, equipment cleanliness, and handwashing before donning gloves and during food preparation.
Call Lights Not Within Reach, Delayed Response, and Lack of Respectful Care
Penalty
Summary
The facility failed to ensure that residents had call lights within reach, that call lights were answered in a timely manner, and that staff were respectful when entering residents’ rooms and providing care. During interviews, multiple residents reported long waits for call lights to be answered, including waits of 30 minutes or longer, and described staff answering the light but not returning to meet their needs. Residents also reported staff using personal phones or appearing distracted while providing care. Resident #75, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, paralytic gait, anxiety disorders, and major disorders, and who had a BIMS score of 14/15, reported that he had wet his pants and believed he was being ignored when staff did not come after he activated his call light. The surveyor observed the call light response time after the resident activated it again, and a CNA entered the room 18 minutes later. The CNA stated she had been in the dining hall feeding another resident and confirmed that the call light monitoring screen showed the wrong time, date, and year. Resident #3 and the resident’s POA reported delayed call light response, with waits of about 45 to 50 minutes, and described staff being found on phones or computers in the hall. Resident #60, who had diagnoses including right great toe fracture, cellulitis, atherosclerosis with gangrene, MDRO, diabetes, and a right hallux amputation, reported that staff barely knocked before entering his room and that this was disrespectful and lacking dignity. The surveyor also observed his call light tied around a nightstand drawer handle and out of his reach. Resident #86, who had diagnoses including RSV pneumonia, fall, cellulitis, bilateral lower extremity lymphedema, PVD with venous insufficiency, and CKD stage 2, was observed with her call light hanging off the bed and on the floor out of reach, and she reported that staff did not listen to her and left items such as her breakfast tray and room cleanup unfinished. Additional residents in a confidential group reported that staff were on their phones while providing care and that call lights were not answered quickly enough.
Lack of Timely Physician Assessment After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician assessments and documentation for two residents following a resident-to-resident physical altercation that resulted in facial injuries. On the morning of 10/18/2025, two residents engaged in an altercation near the facility café while in line, during which one resident struck the other in the face. A nurse (Nurse W) encountered the residents immediately afterward, separated them, and assessed both for injuries. Nursing documentation for both residents on 10/18/2025 described new in-house acquired facial abrasions that were bleeding, which were cleaned with normal saline and left open to air, and indicated that the physician (Physician U) was notified. For the first resident, who had diagnoses including Alzheimer’s dementia, diabetes, depression, kidney failure, hypertension, gout, GERD, and a history of falls, the MDS showed intact cognition with a BIMS score of 15/15 and a need for some assistance with care. Nursing notes documented scratches to the nose and face, and a Skin & Wound Evaluation recorded a new facial abrasion measuring 0.6 cm by 0.4 cm that was bleeding. Although the wound note indicated the physician was notified, the subsequent physician visit note dated 10/20/2025 listed the chief complaint as “altercation with a resident” but did not mention that the resident had been hit in the face, did not describe the facial wound, and did not document a physical assessment of the injury. The resident’s behavior care plan referenced involvement in a resident-to-resident physical altercation but did not mention that the resident was injured. For the second resident, who had diagnoses including autism, mild intellectual disabilities, epilepsy, mood disorder, restlessness and agitation, heart disease, history of stroke, peripheral vascular disease, gout, and hypothyroidism, a prior care transition note indicated moderately impaired cognition with a BIMS score of 12/15. Nursing documentation on 10/18/2025 described scratches to the left side of the face, and a Skin & Wound Evaluation recorded a new in-house acquired abrasion on the left cheek measuring 3.3 cm by 1.6 cm that was bleeding and had been cleaned, with notation that the physician was notified. A physician visit note dated 10/20/2025 listed the chief complaint as “altercation with other resident” but did not mention a skin assessment or that the resident had been hit in the face. A later provider note on 10/30/2025 documented a skin inspection with “no rash or lesions,” but there was no earlier physician assessment of the facial injury. Surveyors determined there was no physician or provider assessment of either resident’s injuries from the 10/18/2025 altercation until 10/30/2025, and the facility’s policy stated that each resident’s medical care is under the supervision of a licensed physician who participates in assessment and care planning and monitors changes in medical status.
Failure to Provide Timely Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide timely and appropriate beneficiary notifications, including the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), for two residents reviewed for Medicare/Medicaid coverage and liability notice. For one resident, the electronic record showed Medicare Part A billing changed to private pay effective 8/30/25, but the facility did not issue the NOMNC or ABN on the last covered day. The Social Worker stated the facility believed the last covered day was 9/5/25, but corporate billing later corrected that date to 8/30/25, and by then it was too late to issue the notices. The Business Office Manager also stated the ABN was missed because the correct last covered day had already passed, and the resident then remained in the facility as private pay until Medicaid eligibility was established. For the second resident, the NOMNC indicated skilled nursing coverage was ending on 12/27/25, and the Social Worker stated she issued the NOMNC to the resident’s wife, who was the POA, on 12/23/25. However, the ABN documentation was inconsistent: the Business Office Manager stated the ABN had been issued and signed by the wife, but the date on the document had been altered with whiteout and changed to an earlier date because she was unsure when the ABN should be dated. The wife later stated she was not at the facility on 12/24/25 and remembered signing papers during a visit after Christmas. During QAPI review, the Administrator and corporate staff had no comment regarding the findings.
Failure to Provide Nail Care and Handwashing Assistance
Penalty
Summary
Failure to provide ADL assistance was identified for one resident who had diagnoses including stroke affecting the left non-dominant side, depression, bipolar disorder, anxiety disorder, and metabolic encephalopathy. The resident’s MDS indicated intact cognition and need for substantial/maximal assistance with bathing and personal hygiene. During observation, the resident was seen eating in bed with chocolate on the overbed table, bed sheet, blanket, and bed frame, and staff did not assist with cleaning the chocolate or offer handwashing. The resident’s right hand had long fingernails with debris under the nails and dried red-tainted debris around the cuticles, and the resident stated he liked short nails and that nail care had not always been offered. On a later observation, the resident’s fingernails remained long on both hands with debris still present under the right-hand nailbeds and red debris around the cuticles. After staff set up the lunch tray, they did not offer handwashing before the meal. The DON acknowledged the resident needed attention and stated the resident’s hands would need to be washed because they were visibly soiled. The record review also showed a lack of documentation of refusal of nail care, while the care plan reflected the resident was known to refuse nail care; the DON stated refusals were not always documented if the care was planned and that shower documentation was being used to reflect nail care completion.
Unsecured Medication Left at Bedside
Penalty
Summary
Medications were not securely stored for safe administration when a family member found a small white pill sitting on the over-bed tray of a resident who had severe cognitive impairment. The resident was admitted for skilled nursing care related to chondrocostal junction syndrome, a subsequent fall, acute with chronic respiratory failure, MI, COPD, and dementia, and her BIMS score was 6/15. The family member asked staff what the pill was and whether it was supposed to be taken, but the ICP nurse said she did not know because she was not the resident’s nurse and took the pill away. Later, the resident’s nurse identified the pill as prednisone, which matched the resident’s morning order for prednisone 5 mg by mouth in the morning, but she said she had witnessed the resident take her morning medication and did not know where the unsecured pill came from. The family member reported concern that the resident may have missed other medications and said the resident could not explain what the pill was or whether she needed it. The ICP nurse stated she was unsure whether the pill had been left from the prior day and could not verify when it had been left at the bedside. The facility policy stated medications and biologicals are to be stored safely and securely, accessible only to authorized personnel, and medication rooms, carts, and supplies are to be locked when not attended.
Failure to Follow Enhanced Barrier Precautions During Wound and PEG Tube Care
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) for residents with qualifying wounds and a PEG tube. Resident #60 had diagnoses including a right great toe fracture, cellulitis of the right toe, atherosclerosis with gangrene, Proteus Mirabilis Morganii, diabetes mellitus, and a right hallux amputation with hyperbaric oxygen therapy. The resident was cognitively intact and had an order for EBP due to a wound, with wound care orders for the right foot and left foot toes. During observation, EBP signage and PPE were present outside the room, and the infection control nurse stated the precautions were in place for wounds. During wound care for Resident #60, a nurse was observed placing unwrapped rolls of gauze directly onto the resident’s bed before applying them, without a barrier covering the linen. The resident also reported repeated staff visits early in the morning and concern about attempts to clip toenails and about the tightness of the dressing. The infection control nurse later acknowledged that staff had recently been trained and that it was known to use barriers and PPE. Resident #9 had diagnoses including cerebral infarction, dysphasia, aphasia, palliative care, PEG tube, and obstructive uropathy, and had severe cognitive impairment with a BIMS score of 0/15. The resident had EBP orders for a foley, PEG tube, and wound. During care, a nurse provided PEG tube medication administration and ostomy site care while wearing gloves only and initially without a gown, despite the resident’s EBP status. The nurse also placed supplies on the bedside table without a barrier, handled the uncapped morphine syringe, flushed the PEG tube, and administered the medication via the tube before recapping it. The nurse stated she had not realized a gown was needed until she looked at the door sign for EBP.
Failure to Ensure Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure the dignity of several residents by not having call lights within reach and not responding to them in a timely manner. Resident #73, who has multiple health issues including memory deficits and confusion, was observed unable to reach his call light, which was hanging over the breathing machine's tubing. During a confidential Resident Council group meeting, several residents complained about the excessive time staff took to answer call lights, with one resident stating they soiled themselves due to the delay. Another resident mentioned that staff were talking on their phones in their room, and some residents reported having accidents because of the delayed response to call lights. Additionally, Resident #66 was left in the bathroom for 16 minutes without assistance, despite requiring substantial help due to severe cognitive impairment and physical limitations. A visitor had to assist the resident and loudly requested staff assistance, but the staff present did not respond until prompted by a Unit Manager. Resident #68 reported that although their call light was within reach, staff were slow to respond when it was used. Resident #281 also stated that while their call light was always in reach, the response time varied significantly, sometimes taking up to 12 hours. These incidents highlight the facility's failure to adhere to its dignity and call light policies, which emphasize prompt response to residents' needs.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 20.69% error rate during the survey. This was observed in the administration of medications to three residents. For Resident #34, a Licensed Practical Nurse (LPN) did not prime the insulin pen before administration and held the pen in place for only four seconds instead of the required ten seconds. Additionally, the resident's blood glucose was checked and insulin was administered after the resident had already eaten breakfast, contrary to the prescribed procedure. For Resident #288, the LPN applied a Lidocaine patch with Menthol, which was not in accordance with the resident's order for a plain Lidocaine patch. The previous patch was not removed as scheduled, and the new patch was applied without proper adherence. Furthermore, the LPN failed to instruct the resident to rinse and spit after administering Symbicort, as required by the medication administration protocol. Resident #28 received three different eye drop medications in quick succession without the required waiting period between administrations. The Registered Nurse (RN) did not apply pressure to the tear duct or instruct the resident to close their eyes after administering the eye drops, which is against the facility's policy. These actions and inactions contributed to the high medication error rate observed during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications and medical supplies in accordance with professional standards. During an observation and interview, it was found that controlled substances were not stored securely, as evidenced by used oral medication syringes being left in the narcotic cabinet. The Registered Nurse (RN) admitted that these syringes were reused for a hospice resident receiving liquid morphine, despite having an adequate supply of new syringes. This practice raised concerns about infection control, especially since multiple resident medications were stored in the same cabinet. Further inspection of the medication storage rooms revealed several issues, including open and undated vials of medications, expired saline solutions, and visibly soiled containers. The Unit Manager acknowledged that over-the-counter medications were not dated when opened and were improperly stored in the medication room instead of in-room cabinets. Despite previous training to prevent such practices, open medications were found in the medication room, and there was no documentation of medications removed from hallway cabinets, which were reportedly shut down a year ago. Additionally, a resident's room was found to have a bottle of iodine left unsecured on the dresser. The resident, who has severe cognitive impairment, was unaware of the iodine's presence. The Licensed Practical Nurse (LPN) confirmed that the iodine should have been secured in a medicine cabinet and speculated that it was left out by the night nurse after wound care. The facility failed to provide a policy or procedure related to medication storage when requested by the surveyors.
Failure to Update and Individualize Care Plans for Residents
Penalty
Summary
The facility failed to update and individualize care plans for two residents, leading to potential safety risks and unmet needs. Resident #28, who has a history of falls and multiple medical conditions including vascular dementia and poor mobility, was not supervised while outside the facility. Despite being at high risk for falls, the resident's care plan did not include interventions for supervision during outdoor activities. This oversight resulted in the resident tipping over her wheelchair outside, leading to a hip fracture and hospitalization. Resident #55, who has chronic health issues and requires substantial assistance with daily activities, developed a new skin impairment that was not documented or addressed in the care plan. During a wound care observation, a large excoriation was found on the resident's lower back, but there was no documentation of the assessment, treatment, or care plan update for this condition. The nursing staff assumed that documentation would be completed by others, resulting in a lack of recorded care for the skin impairment. The deficiencies highlight a failure in the facility's processes for updating and individualizing care plans based on residents' changing needs and conditions. The lack of documentation and communication among staff contributed to the oversight in care planning, potentially compromising the residents' safety and well-being.
Failure to Document and Address Skin Care Needs
Penalty
Summary
The facility failed to ensure comprehensive skin care for a resident, resulting in a deficiency related to skin and wound care. The resident, who was admitted with multiple diagnoses including Chronic Diastolic Congested Heart Failure and Severe Morbid Obesity, complained of pain and discomfort due to a small bed that limited her movement. This limitation contributed to the development of a sore on her back. During a wound care observation, it was found that the resident had developed a 14-inch excoriation across her lower back, described as Moisture-Associated Skin Damage (MASD). Despite the presence of multiple staff members during the assessment, there was no documentation of the skin impairment, treatment, or updated care plan in the resident's clinical record. The deficiency was further compounded by a lack of communication and documentation among the staff. The nurse manager assumed that the nurse who performed the assessment would document the findings, while the corporate clinical staff believed the nurse manager would handle the documentation. As a result, there was no record of the skin assessment or treatment in the resident's notes, and no physician order was documented for the newly observed skin impairment. Additionally, the facility did not provide the requested policy for Skin Care and Wound Management, highlighting a gap in procedural adherence.
Failure to Implement Wheelchair Safety Procedures
Penalty
Summary
The facility failed to implement policies and procedures to mitigate the risk of injury during wheelchair transport for a resident. On a specific date, a resident was observed being pushed down the hallway in a wheelchair without footrests by a CNA. The resident was attempting to hold their legs up, and their feet were observed getting closer to the floor as they were pushed. The CNA confirmed that they were pushing the resident without footrests and acknowledged that most residents did not have footrests available for their wheelchairs. The CNA expressed surprise at the lack of footrest availability, as it was a requirement for resident safety at other facilities they had worked at. The resident involved had a history of dementia, chronic kidney disease, hallucinations, and repeated falls, with a care plan addressing their risk for falls. However, there was no care plan in place regarding footrest use while being pushed in a wheelchair. The facility's RN revealed that the need for footrests was based on individual residents, and there was no policy or procedure related to wheelchair mobility and foot pedal use. A policy or procedure pertaining to wheelchair transport was requested from the facility Administrator but was not provided by the conclusion of the survey.
Lack of Physician's Order and Documentation for Catheter Changes
Penalty
Summary
The facility failed to ensure that a physician's order was in place for indwelling catheter changes and that these changes were documented for a resident. The resident, who is of advanced age, was admitted with diagnoses including kidney failure, depression, hypertension, and surgical aftercare following genitourinary surgery. During a record review, it was found that while there was a care plan for catheter use, there was no order specifying intervals for changing the catheter. The resident recalled a recent catheter change due to leakage, but there was no documentation in the electronic medical record to confirm this change. An interview with a registered nurse revealed that there should be at least an as-needed order for catheter changes and documentation when a catheter is changed. The facility's policy on catheter care, revised in October 2010, suggests changing catheters based on clinical indications rather than fixed intervals and requires detailed documentation of catheter care. However, in this case, the absence of a physician's order and lack of documentation for catheter changes were identified as deficiencies.
Failure to Provide Timely Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide timely and appropriate dialysis care for a resident who required such services. The resident, who is cognitively intact, was admitted with diagnoses including acute kidney failure, chronic kidney disease, congestive heart failure, and dependence on renal dialysis. Despite attending dialysis sessions, the facility did not enter a physician's order to monitor the dialysis perma-cath site until after the resident had already received dialysis on two occasions. This delay resulted in the absence of necessary monitoring of the dialysis perma-cath site. Additionally, the facility did not follow a physician's order to complete the Wellbridge Dialysis Assessment form. The form was incomplete for one dialysis session and entirely missing for another. The Infection Control Nurse confirmed that the forms should have been completed and acknowledged the oversight in entering the physician's order for monitoring the dialysis perma-cath site. The facility's policy on the care of residents with end-stage renal disease outlines the importance of staff education and training, including the need for timely and accurate documentation and monitoring.
Sanitation and Equipment Maintenance Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, as well as ensure proper maintenance of kitchen equipment, specifically the dishwasher. During an inspection, it was observed that the inside door of the ice machine had a build-up of a calcium-like hard white substance on the door gasket, which was directly over the ice. Although the facility had identified this issue and ordered new gaskets, the problem persisted. Additionally, clean knives and silverware were found with dried food particles, and clean pans were stacked with water and food particles inside them, indicating improper cleaning and drying practices. Furthermore, there was an excessive amount of standing water on the floor in front of the dishwasher, which was found to be leaking from the drain trap. The facility's Infection Control Nurse, who was new to the role, had not been shown how to conduct a kitchen infection control tour, and there was no documentation of inspections for the dishwasher or ice machine in the facility's Interdepartmental Infection Control Rounds sheets. These deficiencies affected 81 residents who consumed oral nutrition from the facility kitchen.
Failure to Implement Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to implement proper hand hygiene practices during medication administration, as observed with two residents. During a medication pass observation, a Registered Nurse (RN) did not perform hand hygiene before entering the room of the first resident or before preparing and administering medications. Similarly, the RN did not perform hand hygiene before entering the room of the second resident or before obtaining and administering medications. An interview with a Clinical RN confirmed that staff should perform hand hygiene before and after medication administration. The facility's policy on medication administration, dated 9/1/23, requires handwashing and sanitization before beginning a medication pass, prior to handling medication, and after direct contact with a resident.
Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, particularly in relation to the accessibility and timely response to call lights, as well as the involvement of resident representatives in care planning. Several residents reported issues with call lights not being within reach or not being answered promptly, leading to unmet care needs and feelings of frustration. For instance, one resident was unable to reach their call light and reported waiting over 30 minutes for assistance, while another resident resorted to yelling for help due to delayed responses. Additionally, there were reports of poor attitudes and disrespectful behavior from staff members. One resident described aides as having bad attitudes and not being nice, while another resident reported a CNA being verbally and physically abusive. This included an incident where a CNA yelled at a resident for taking too long to get to the bathroom and physically grabbed the resident's gown. The resident expressed feeling unsafe and uncomfortable in the facility. The facility also failed to adequately involve resident representatives in care planning and communication. A resident's family member reported difficulties in obtaining a list of medications and participating in a care conference due to technical issues. This lack of communication contributed to a situation where a resident was administered a medication that had previously caused severe health issues, ultimately leading to the resident's death. The facility's policies on resident rights and call light response were not adhered to, resulting in significant deficiencies in the care provided.
Failure to Monitor and Report Post-Fall Decline
Penalty
Summary
The facility failed to promptly monitor and inform the physician regarding the declining status of a resident following a fall, which resulted in a delay in treatment and hospitalization. The resident, who was on anticoagulant therapy due to a history of atrial fibrillation, experienced two falls within a short period. After the second fall, the resident's mental status began to decline, showing signs of lethargy and sluggishness, which were not immediately communicated to the physician. The nurse manager, who was not present during the falls, assessed the resident later in the day and noticed a change in the resident's condition. Despite these observations, the nurse practitioner was only informed of the fall and ordered COVID-19 testing and precautions without evaluating the resident in person. The resident's family, noticing the decline, insisted on hospital evaluation, where a brain bleed was diagnosed. The facility's fall policy required monitoring for delayed consequences of falls, including neurological assessments, which were not adequately followed. The lack of timely communication and assessment contributed to the delay in recognizing the severity of the resident's condition, ultimately leading to hospitalization for a brain bleed.
Delayed Wound Care Orders and Care Plan Updates for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to timely enter a physician's order for wound care and update a skin integrity care plan for a resident with pressure ulcers. The resident, who is severely cognitively impaired and unable to communicate effectively, was admitted with conditions including cerebral infarction, contractures, and dementia. During the survey, the resident was observed with dressings on both elbows, which were propped on pillows for pressure reduction. The resident developed a Stage 3 pressure ulcer on the left elbow and a Stage 2 ulcer on the right elbow, both acquired in-house. However, orders for wound care were not placed until four days after the ulcers were identified, and the care plan was updated six days after the development of the ulcers. Interviews with nursing staff revealed a breakdown in the process of wound identification and care plan updates. An LPN stated that orders should be entered as soon as a wound is identified, ideally the same day. However, the RN who identified the wounds did not enter an order into the electronic medical record, instead applying a foam dressing and notifying the next shift and management. The RN expressed discomfort with updating care plans, which contributed to the delay. The facility's policies require timely physician orders for wound treatment and prompt care plan revisions when a resident's condition changes, but these protocols were not followed in this instance.
Improper Storage of Nebulizer Equipment and Oxygen Administration
Penalty
Summary
The facility failed to properly store nebulizer equipment and follow physician's orders for oxygen administration for two residents. Resident #3, who has diagnoses including congestive heart failure and chronic respiratory failure, was observed with a nebulizer machine on the nightstand containing liquid in the medication chamber, which was not in accordance with the facility's policy for nebulizer equipment storage. Additionally, Resident #3 was receiving oxygen at 3 liters per minute, contrary to the physician's order for continuous oxygen at 2 liters per minute. The LPN on duty was unaware of why there was fluid in the nebulizer chamber and later adjusted the oxygen flow to the correct rate after verification. Resident #10, who has severe cognitive impairment and diagnoses including pneumonia and Alzheimer's disease, was found to have a nebulizer mask setup with fluid in the medication chamber on an overbed table. The nebulizer had last been signed out at 8:00 AM, but the equipment was not stored properly as per the facility's policy. An LPN acknowledged the issue and disposed of the nebulizer. The facility's policies for nebulizer equipment and oxygen administration were not followed, leading to these deficiencies.
Failure to Obtain Timely Physician Visit Documentation
Penalty
Summary
The facility failed to obtain timely physician visit documentation for a resident, resulting in delayed implementation of treatment orders and the potential for inappropriate physician's orders. The resident, who was admitted with diagnoses including Atrial Fibrillation and Chronic Respiratory Failure, experienced a gap in physician visits exceeding 60 days, contrary to the facility's policy requiring visits at least once every 60 days after the first 90 days of admission. This gap was identified during a review of the resident's electronic medical records, which showed that the resident was seen by a practitioner on several dates, but there was a significant gap between two specific dates. The Nurse Practitioner (NP) involved in the resident's care acknowledged the gap in visits and explained the protocol of alternating visits with the physician. The NP recalled being informed of the resident's fall but did not examine the resident post-fall, as the symptoms reported were considered baseline. The resident, who was on anticoagulant therapy, fell twice and was later diagnosed with a brain bleed after being sent to the emergency room. The NP did not recommend sending the resident to the hospital initially, as no abnormal neurological symptoms were reported at the time. The facility's Physician Visit Policy was reviewed, revealing the requirement for regular physician visits, which was not adhered to in this case.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its policy for Enhanced Barrier Precautions (EBP) during wound care for a resident, resulting in a deficiency. The resident, who is severely cognitively impaired and unable to communicate effectively, was admitted with conditions including cerebral infarction, contractures, dementia, and age-related physical debility. A physician's order dated September 5, 2024, required the use of gowns and gloves for high-contact care activities, including wound care, due to the resident's conditions such as a foley catheter, peg tube, and pressure wound. On October 24, 2024, a nurse performed wound care on the resident without wearing the required personal protective equipment (PPE) for EBP. The nurse, along with a hospice caregiver, conducted the wound care procedure without donning gowns and gloves, which are mandated for high-contact care activities. Upon completion, the nurse acknowledged the oversight when informed of the EBP requirement. The infection control nurse confirmed that staff are expected to follow EBP guidelines, which include wearing gowns and gloves for high-contact activities, and stated that monthly education is provided to staff on these protocols.
Inadequate Post-Fall Monitoring and Documentation
Penalty
Summary
The facility failed to adequately document and monitor post-fall incidents for two residents, leading to deficiencies in care. Resident #701, who was on a hospice respite stay, experienced a fall without any subsequent post-fall monitoring or neurological checks documented. The resident had severe cognitive impairment and required assistance with activities of daily living. Despite the fall being reported, there was no documentation of any injuries or follow-up care before the resident was discharged home. Resident #703 experienced three consecutive falls while attempting to go to the bathroom, resulting in injuries including a scalp bruise and a goose egg on the forehead. The facility did not implement meaningful interventions to prevent further falls, and there was a lack of consistent neurological checks and monitoring of injuries. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was not toileted appropriately, which contributed to the falls. The facility's interventions, such as clipping the call light to the blanket and ensuring adequate lighting, were not effective in preventing further incidents. Interviews with the Director of Nursing and Unit Manager revealed that the facility's response to the falls was inadequate, with missing documentation and inconsistent neurological checks. The facility's policy on fall reduction was not followed, as there was a lack of physical assessment and documentation after the falls. The staff acknowledged the deficiencies in monitoring and documentation, indicating an understanding of the concerns raised.
Failure to Provide Person-Centered Behavioral Health Care
Penalty
Summary
The facility failed to ensure communication between clinical services and social services to develop a person-centered care plan for Resident #501, resulting in unmet care needs and a lack of individualized approaches to care. Resident #501, who had a history of brain bleed, schizophrenia, visual loss, and other medical conditions, was admitted to the facility and exhibited significant behavioral issues, including combativeness and refusal of care. Despite these behaviors, the facility did not develop specific resident-centered interventions and relied on generic care plans that did not address the resident's unique needs and preferences. The progress notes revealed that Resident #501 repeatedly refused care, was combative, and had episodes where she was found with feces on her body. The staff's approach to managing her behavior was inconsistent, with some staff members being able to provide care while others were not. The facility's response to her behavioral issues was inadequate, as they were waiting for a psychiatric evaluation that had not yet occurred. The resident's care plan lacked specific interventions to address her schizophrenia and behavioral symptoms, and there was no documented order for a behavioral health referral. On one occasion, EMS staff found Resident #501 alone in a dark bathroom, covered in feces, and emotionally distressed. The EMS report indicated that the resident was alert and oriented but was left in unsanitary conditions without proper supervision. The facility staff did not provide an adequate explanation for why the resident was left in such a state, and the EMS staff had to clean her up before transferring her to the hospital. This incident highlights the facility's failure to provide necessary behavioral health care and services, resulting in unmet care needs and emotional distress for the resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 364 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fenton Healthcare | 1 mi | ★★★★★ | 5 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 3.2 mi | ★★★★★ | 23 | 0 |
| Caretel Inns Of Linden | 4.5 mi | ★★★★★ | 40 | 0 |
| Wellbridge Of Grand Blanc | 6.1 mi | ★★★★★ | 14 | 0 |
| The Oaks At Woodfield | 7.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.